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Diane Nanno
Transition Coach
Crouse Hospital
Syracuse, NY

Crouse Hospital addresses the needs of its congestive heart failure patient population using a transition coach, an idea developed by Eric Coleman, MD, at the University of Colorado at Denver. Diane Nanno explains the service, launched last September, and how it prevents seniors from falling through the cracks during transitions in care.

Nanno: I set patients up with a personal health record that contains demographic information, physicians and phone numbers, medical history, and hospitalization history. There's also a personal medication record that includes what the medication is for, who ordered the medication, and when they started. Seniors who come to the hospital often don't know what medications they're on or they don't know the dose, which is critical. The idea behind this is that they'll have a dynamic, updated record so everyone that's taking care of the patient knows.

I set a functional goal with the patients. I ask them, "What haven't you been able to do that you would like to be able to do again?" The goals are usually very simple, like "I'd like to be able to walk to the mailbox."

I see patients on the floor, and I make a home visit once they are discharged. I follow them on the phone at least weekly for 30 days. After 30 days, I check in periodically. I make sure that they have a follow-up appointment, a way to get there, and that they've actually followed through with that appointment.

-Molly Rowe

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